Visa going direct into health payments market

Have some pie: This is "pie in the sky". I have worked in managed care since 2002 collecting for hospitals from all the insurers, self-funded ERISA and other plans that approve treatment and then don't pay.

Every carrier and plan reads a disclaimer which says basically, "Certification is not a guarantee of payment. Eligibility is determined when the claim is received."

There is also the problem of retroactive cancellations. For instance, someone just left his job and the insurer/plan hasn't been told, so it "verifies benefits", and then weeks or months later is told the person was not employed and there was not coverage. If the insurer/plan has paid it demands a refund. If the provider refuses, the insurer/plan "recoups" by offsetting the amount against other monies the plan owes.

Most networks/insurers draft their own managed-care contracts which include something to the effect that if the person is not covered, the provider bears the risk, not the payor, e.g., the person signs up for insurance, gets the card, and then stops paying premiums.; Posted by: Rick_R Posted on: 03/13/09 You are currently: a Guest | Members login | Terms of Use